'Serious failures' in lead-up to pensioner's death, inquest hears

PENSIONER Stewart Maltby died following a catalogue of errors by the NHS – including an ambulance wait of over four hours, an inquest heard.

The coroner's ruling at Nottingham's Council House yesterday said there were "serious, repeated and systemic failures" during the 64-year-old's care in the lead-up to his death from kidney failure.

This included delays getting him to hospital and further hold-ups at the Queen's Medical Centre – meaning it was 14 hours before he got the fluids his GP had said he needed when he initially called for an ambulance.

Both East Midlands Ambulance Service and the QMC have apologised to Mr Maltby's family for the failings and said lessons had been learned.

During the hearing doctors and nurses gave what the coroner called "candid" evidence, with each one blaming a lack of time and being short-staffed.

Assistant Coroner Jane Gillespie said: "These failures were far-reaching and impacted on all aspects of his care, from basic observations and recordings, to a delay in the escalation of his care and a failure to review his condition by an appropriately senior doctor when necessary.

"All the while... Mr Maltby's condition continued to deteriorate and those caring for him were oblivious to the same."

The inquest heard that Mr Maltby's GP Dr John Porter called an ambulance at 1.53pm on November 5, 2012, requesting the vehicle to arrive within two hours as he needed to be treated with IV fluids.

Despite phoning again to make the call into a 999 priority – meaning it should have arrived within 20 minutes – it took until 6.19pm for paramedics to show up due to an oversight in the control room by a dispatcher. And the mistakes continued after Mr Maltby, of Farnsfield, was admitted to Ward D57 at Queen's Medical Centre at 7.54pm, the inquest was told.

Failures by medical staff to conduct observations, record reliable information and update medical records led to Mr Maltby not getting any IV fluids until 3.50am the following morning.

Despite medical staff identifying he needed urgent fluid management, the five litres he should have received over the first 24 hours of his care only resulted in two litres being given.

After two days and doctors realising too late that the only course of action to save Mr Maltby would have been surgery, he died on November 7, 2012.

In a narrative verdict, Assistant Coroner Gillespie said: "During the period of his admission, there were several missed opportunities when the correct treatment plan could and should have been pursued. I find that had this been so, the outcome may have been different."

The family of Mr Maltby praised the coroner's verdict, as well as improvements made by both the ambulance service and QMC since his death.

A statement from the family read: "It is clear that the initial reply from the ambulance service to our complaint about the delayed response to the call for an ambulance that they were 'very busy' was simply paying lip service to their initial failings in this unfortunate and distressing series of events.

"In his short and tragic time at the QMC, Stewart was dealt with by around 36 people.

"Some were clearly shown by the inquest to be hard-working, dedicated individuals struggling in a highly-pressured environment with little support from management despite direct and repeated requests for additional assistance."

The family concluded: "Stewart was a character who made us laugh with his mischievous sense of humour. He spent a lot of time caring for others, often to his own detriment. 18 months on he is still very much missed by us all."

Peter Homa, chief executive of Nottingham University Hospitals NHS Trust, said: "We extend our condolences and reiterate our unreserved apologies to Mr Maltby's family for the failings in our care and for letting them and their father down so badly.

"The absence of regular clinical observations, handovers between staff and failure to administer fluids appropriately meant Mr Maltby's rapidly deteriorating condition was not acted upon as it should have been.

"We have learnt from this sad and tragic case and made changes to improve safety and outcomes for our future patients."

A spokesman from the ambulance service added: "The service we provided to Mr Maltby fell short of the high standard our patients should expect, and we are very sorry about that."

"We have since initiated a number of changes and issued guidance to all control staff to ensure that the same error can't be made when entering bookings in future."

9 comments

How many more times are we going to listen to those hollow words , Lessons have been learnt, don't make me laugh lessons are never learned and its time the coroner woke up and smelt the coffee and told these hospital over paid bigwigs get your house in order or you will suffer the consequences .

Oerhaps EMAD to save a spokesperson said should have a pre recorded comment to play over the phone sayibg Sorry your relative died but are learning a lesson from tbe ibcident. Not good enough another innocent member of the public losses his life due to incompetent managers. How many more people need pay with their lives before the NHS takes over this failed organisation and rid the hard working dedicated ops. Staff of the dead wood "managers"? Come on the overseeing commitee, bet you will say you are supporting EMAS management in improving the service.....

My father in law was in the QMC just after Christmas with pneumonia. He was more or less left to his own devices despite suffering from dementia. On one occasion we found him drinking barrier cream because he thought it was medicine he was supposed to be taking. He should have been on a geriatric ward imo.